Complex peripheral nerve injury

Examination

• Examine the peripheral nervous system for all injuries and document findings.
• Repeat examination after any manipulation or surgery.

Management

• Reduce fractures/dislocations urgently if there is an associated nerve injury.
• The following requires appropriate surgical expertise to explore the wounds:
  • Laceration near a nerve associated with a neurological deficit.

Investigations

• Neurophysiology is rarely needed acutely and must not delay referral or treatment.
• MRI can assist in surgical planning but is not essential and surgery should not be delayed waiting for scan.

Surgery

• Explore the nerve during internal fixation of fractures associated with nerve injury except axillary nerve (with low energy shoulder trauma) and Lumbosacral plexus injury (during sacroiliac screw fixation).
• Document exploration of the nerve in the notes and the proximity of the nerve to any internal fixation device.
• Nerves damaged during surgery should undergo urgent repair.
• If a divided nerve is found during surgery:
  • If skilled and able, repair the nerve.
  • If not, oppose nerve with fine coloured sutures & Refer.

Post-surgery Complications

If a new vascular or nerve deficit post-surgery develops:

• Loosen bandages
• Split plaster of paris to the skin
• Gentle repositioning of limb
• If no improvement, consider re-exploration.

Explore painful post-operative paralysis urgently, it could be:

• Compartment syndrome
• Nerve compression from:
  • Bone fragments
  • Suture
  • Haematoma
  • Hardware.

 Explore pain and progressive loss of sensation urgently as critical ischaemia is likely.